Nonsense or necessity? Doctors divided on NHS e-Referrals

With the deadline for going paperless less than a year away, Gill Hitchcock finds that front-line workers have differing views on health service’s tech systems

“Clearly nonsensical.”

That’s Dr Paul Cundy’s comment on the October 2018 deadline for all GPs to have abandoned old paper systems to book hospital appointments for their patients and use the NHS e-Referral Service instead.

Does Cundy, the IT policy lead and chair of the British Medical Association’s committee of GPs, who says he has spent his entire career promoting IT, have a point?

Every day about 60,000 referrals into secondary care are made across the health service. NHS Digital, the body overseeing the electronic booking system, believes that making these referrals online relieves the burden of paperwork on GPs, is cheaper than using paper, removes the risk of losing letters and allows doctors to track their patients' referrals more easily.

The e-Referral Service was launched in 2015. Since then, there have been a number of initiatives to encourage people to use it. For instance, there is a website for patients to book, or change, a hospital appointment. The idea is that they can achieve this with a few clicks on their mobile phone or tablet. And last year, NHS England created a £55m fund to reward GPs and hospitals for switching to digital referrals. It was calling time on the practice of referring patients to hospital by second-class post, it said.

"Everyone seems to conveniently forget that we send out about four pages of notes on how patients can get their appointments, with a password to log in. The idea that it is paperless is complete nonsense"
Dr Paul Cundy

At that point, only 50% of patients were referred for hospital appointments electronically, but NHS England predicted this would increase rapidly. It would reach 60% by September 2016, 80% in 2017, and 100% by 2018. With less than 12 months to go, however, usage is stuck at 57%.

Just two NHS trusts – Sherwood Forest Hospitals, and County Durham and Darlington – are accepting only digital referrals. Patients who are unable to access the internet have the option of a using the telephone.

Dr Cundy says his south London practice – which has six doctors, only half of whom use the e-Referral Service – provides a snapshot of the current situation.

He is among those who do not, and he explains why: “There are two fundamental elements that are required. First, the functionality needs to be much quicker for GPs. It has to be speeded up.

“Second, when you do an electronic referral, everyone seems to conveniently forget that we send out about four pages of notes on how patients can get their appointments, with a password to log in. The idea that it is paperless is complete nonsense.”

He also gives another very significant reason why many GPs don’t like using the e-Referral Service: “What the trusts disclose onto this system is up to them, and there is no policing of that. When you go onto a certain clinic, to see a certain doctor at a certain place and time, there is absolutely no guarantee that is what you will be offered.

“If [trusts] are running low on referrals, they chuck up a whole load of clinics which will never [actually take place]. And if they are running low on capacity, they reduce the number of appointments displaying on the e-Referral Service, so we can’t book. Basically, they game it. And once a patient is in the system, it’s more difficult to get them out and put them onto another hospital.”

A chance for better care outcomes
The founder of online patient forum IWantGreatCare, Dr Neil Bacon, believes the e-Referral Service is an opportunity for innovation. This is, not least, because it could be designed to help patients to make informed choices about hospital services.

A range of factors – hospitals closures, the fragmentation of the health service and a more mobile workforce – have eroded close relationships between GPs and local hospitals. Bacon says it is no longer reasonable to expect every GP to have a good understanding and knowledge of every available speciality. Their ability to help patients choose the best care is diminished.

“If you think of online booking for a hotel, you can see information and whether you’re going to the right place,” he says. “What’s vital is that the e-Referral Service has information to help patients get great care, and avoid poor care and poor outcomes.

“The NHS has all that information – about outcomes, [about] which organisation is excellent and so on – and it should be embedded in the electronic booking system. It’s what patients want.”

While the development of its predecessor, Choose and Book, was outsourced to Atos under the NHS National Programme for IT, the e-Referral Service has been developed in-house under the control of the Health and Social Care Information Centre, now NHS Digital. Low usage of the system begs the question, of whether this was the right decision.

Ben Moody, head of health and social care at IT industry body techUK, says it’s hard to hold up Choose and Book as a shining example of how things should be done, but that the answer will, of course, come in 2018.

He is positive about the adoption of open application programming interfaces (APIs). And he welcomes NHS Digital’s continued engagement with suppliers through his organisation where it has presented them with its “roadmap” of challenges and requirements for innovation.

"The NHS has all that information – about outcomes, about which organisation is excellent and so on – and it should be embedded in the electronic booking system. It’s what patients want"
Dr Neil Bacon

“NHS Digital has become much better about being clear on what it’s building versus what it’s buying,” he says. “But there is a danger that suppliers are a sounding board to benefit something that is built in-house and that they invest time and effort into engagement without there being a procurement at the end of it.”

Cundy says that if technology is good, GPs will use it.

Bacon makes a similar point about patients, adding that if they can book or change their appointments easily online, it reduces the number of missed appointments and creates capacity in telephone services for those without internet access. He believes that if patients who want to make informed choices about their care have the information to do so, it helps GPs too.

“We must make sure that the NHS does not see the very lowest functional level as a success, but looks at how can we empower patients,” says Bacon. “The thought of the NHS in 2018 not having a simple, effective, easy-to-use interface is, frankly, embarrassing.”